Vulnerable Llanmartin man who died of hypothermia had been reported missing eight times

Gary Jones, 54, from Llanmartin, had been reported missing to Gwent Police eight times over a 12-month period.

He would voluntarily sleep on the streets or in woods as he felt safer in the open, an inquest hearing was told.

He suffered from “significant mental health problems”, said Senior Coroner for Gwent Caroline Saunders, who was critical of his care team and Gwent Police over what she called the lack of a "consistent approach" toward him.

In 2010, Mr Jones was diagnosed with depression but there was no serious change in his health before 2016.

He then began to be afflicted by extreme anxiety, paranoia, by feeling not real, and thinking the world would end.

Mr Jones’ sister, Lynne Milne, said in a statement: “It is not clear what prompted this and he had led a normal life before.”

Hanka Roudnicka, Bellevue ward manager at St Cadocs Hospital in Caerleon, where Mr Jones was treated, said he was unable to express why he did not feel real.

“He said to me, "I can’t tell you what is wrong, but it is real, and I am not",” she said.

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After being reported missing on November 16 2017, Mr Jones was found by a dog-walker on November 23 near Hazel Farm, Llanwern.

He was airlifted to the University of Wales Hospital, Cardiff, but despite the efforts of doctors, he suffered several circulatory shocks and organ failure, and died nine days later.

A post mortem examination determined that he died of hypothermia, caused by exposure.

That November, Mr Jones had been receiving home treatment after being discharged from St Cadocs, which included fortnightly meetings with a mental health worker.

Staff at St Cadocs discharged him as he responded to treatment better at home than in hospital.

Ms Saunders criticised the lack of a “consistent approach” between the care team and the police.

“At no time was there a strategy meeting or a sharing of information between these agencies to help draw up a plan for Gary.

“I consider this a failure, but I cannot say that it would have led to a different outcome.”

At one point, Mrs Milne said her mother was told by police not to report her son being missing again because it was “wasting police time”.

Chief Inspector Sarah Davies, of Gwent Police, apologised on the force’s behalf if this had been said.

Gwent Police now have a mental health practitioner in-house to help officers approach those who suffer from mental health issues.

Ms Saunders concluded that Mr Jones' death was misadventure.

She also apologised for the length it had taken to conclude the inquest since its opening in December 2017.

“I am afraid that waiting this long for an inquest is frankly unforgivable," she said.